Healthcare associated infections (HAIs) in nursing homes (NHs) are a major safety issue that is often avoidable. For residents living in NHs, infections are among the most common reasons for hospitalizations and are a leading cause of morbidity and mortality. NH hospitalizations related to HAIs are costly, often preventable, and potentially associated with negative health outcomes. Because the majority of care in NHs is provided by nursing personnel, understanding how this workforce provides safe, high quality, cost-efficient care to this rapidly growing population is critical. While associations between nurs staffing and adverse outcomes such as infections are well documented in hospitals, the evidence base that examines these relationships in NHs is limited and is mainly cross sectional. Previous studies have examined the influence of nurse workforce characteristics on quality of care in NHs; however, research examining the impact of nurse workforce characteristics specifically on HAIs and resident acute transfers are limited. Further, economic studies examining the costs and benefits of optimal nurse staffing and decreased resident adverse outcomes are sparse. No published research has simultaneously examined the cost-effectiveness of improving efficacious structures and processes of care for HAI reduction in NHs. Building on the work of a larger study and having access to a unique longitudinal dataset from the Veterans Administration (VA) NH facilities for fiscal years 2003 through 2009, this proposed dissertation study will examine the impact of nursing inputs on resident care processes and outcomes (i.e., HAIs and resident transfers to hospitals). Specifically, the applicant will identify efficacious structures and processes of NH care that impact HAI outcomes and costs. This study will inform the empirical evidence base in NH health services research that will be useful to health policy makers and NH administrators. The applicant's long-term goal is to develop an interdisciplinary program of research to improve the quality of care for older adults by generating knowledge to inform effective health policies with the ultimate goal of promoting quality of life and safety for NH residents. As such, the goals of this project are in alignment with those of the NINR Strategic Plan of caregiving, disease prevention, and improving the quality of life for NH residents. The proposal is also closely aligned with NINR's goals for training future nurse scientists to employ innovative methods such as comparative effectiveness and economic analyses to advance the science of health and quality care. PUBLIC HEALTH RELEVANCE: Healthcare associated infections (HAIs) in nursing homes (NHs) are a major safety issue that is often avoidable. The majority of care in NHs is provided by nursing personnel; understanding how this workforce provides safe, high quality, cost-efficient care to this rapidly growing population is critical. Identifying efficacious structures ad processes of care to improve the quality of and cost-effectiveness of NH care to reduce HAIs will inform future clinical practice and health policy.